title: Frontier America's health system challenges and population health outcomes.
abstract: OBJECTIVE
  The objective of this cross-sectional descriptive study was to examine and compare the county-level characteristics including demographic factors, health system factors, and population health outcomes of frontier and nonfrontier counties in the United States. All counties in the United States were studied using the merged County Health Rankings 2011 and the Area Resource File 2009 databases. Of a total of 3,141 counties in the County Health Rankings 2011 database, 438 were identified as frontier counties using the conventional definition of fewer than 7 persons per square mile.
  
  
  RESULTS
  Frontier counties were found to have a significantly higher proportion of elderly, Hispanic, and Native American residents than nonfrontier counties. Frontier counties have lower household income and lower levels of illiteracy. Frontier counties also have significantly fewer primary care physicians and higher uninsurance rates. Although frontier counties have a lower percentage of ZIP codes with healthy food and recreational facilities, the incidence of obesity is lower in frontier areas.
  
  
  CONCLUSIONS
  Empirical literature on the population health outcomes and health system factors of frontier areas is limited. Frontier communities in the United States face significant challenges in terms of having populations with a higher need for primary care such as the elderly and poor. In addition, they face access barriers due to geographic remoteness. The availability of reliable data on population outcomes will enable policy makers to monitor the health status of frontier populations and to design solutions to the access issues that these populations face.
authors.affiliation: Health Services Research & Administration, University of Nebraska Medical Center, Omaha, Nebraska 68198-4350, USA. pnayar@unmc.edu
authors.forename: Preethy
authors.initials: P
authors.lastname: Nayar
authors.forename: Fang
authors.initials: F
authors.lastname: Yu
authors.forename: Bettye A
authors.initials: BA
authors.lastname: Apenteng
mesh_terms: D003430:Cross-Sectional Studies; D016208:Databases, Factual; D003695:Delivery of Health Care; D003710:Demography; D005260:Female; D062305:Geographic Mapping; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D011159:Population Surveillance; D012424:Rural Population; D014481:United States